What is the definition of hepatitis?
inflammation of the liver.
*can be self-limiting or progress to cirrhosis (fibrosis)
How do you treat Hepatitis A?
- no specific treatment (self-limiting disease )
- hospitalization not necessary unless acute liver failure
- therapy is aimed at maintaining nutritional balance (replacement of fluids and electrolytes lost from vomiting and diarrhea).
How do we prevent Hepatitis A?
- improved sanitation= safe drinking water, proper disposal of sewage, hand washing.
- Hep A vaccine= injectable inactivated virus (2 dose). 100% gain immunity within 1 month of vaccine that lasts 5-8 years.
Who should get the Hep A vaccine?
high incidence areas, men who have sex with men, IVDA, occupational risk, chronic liver disease, household members of adopted children from other countries.
What should you do post-exposure with Hep A?
- immunoglobulin injection and hep A vaccine within 2 weeks after exposure.
Does the Hep B vaccine have core antigen?
NO just surface antigen, meaning you will only develop antibody against the HBsAg.
What is the treatment for acute Hepatitis B?
- No specific treatment.
- supportive care and maintaining nutritional balance.
- can use antivirals in severe acute HBV leading to liver failure.
What is the treatment for chronic Hepatitis B?
- ANTIVIRALS (Tenofovir or entecavir)= nucleotide reverse transcriptase inhibitors, which incorporate into viral DNA, resulting in DNA chain termination.
- Tenofovir can cause renal failure, so use entecavir in a pt with renal problems.
- if cirrhosis then LIVER TRANSPLANT
Is interferon used anymore?
NO
Can you get hepatocellular carcinoma without cirrhosis from hepatitis B?
YES (one of the few diseases that can do that).
*hemochromatosis is another.
** What are the 4 characteristic phases for Hepatitis B? (TEST QUESTION)
- Immune TOLERANT= HBeAg positive NORMAL ALT, high HBV DNA (>2000 IU/mL).
- HBeAg positive immune ACTIVE= ELEVATED ALT, high HBV DNA.
- INACTIVE= HBeAg negative, HBeAB positive, NORMAL ALT, low HBV DNA (less than 2000 IU/mL).
- HBeAg negative immune ACTIVE= elevated ALT, active inflammation, high HBV DNA.
** Who should be treated from the 4 phases? (TEST QUESTION)
only those whom are immune ACTIVE/inflammation (aka have elevated ALT)!!!
*it doesn’t matter what the envelope (HBeAg) status is.
Whom should you consider treating in special circumstances?
- HBsAg persistence > 6 months.
- compensated cirrhotics= stable bilirubin, no ascites, or esophageal varices. Treat because you don’t want the fibrosis to worsen.
When can you defer treatment in chronic hepatitis B?
if they are immune INACTIVE (no inflammation) or immune tolerant.
Is the rate of transmission of HBV from mother to baby during birth high?
YES 84%
When should treatment of the pregnant mother be started for HBV?
THIRD trimester if HBeAg positive or HBV DNA greater than 200,000 IU/mL
What should we do for all newborns of HBV + mothers?
given both the first dose of vaccine and immunoglobulin for prophylaxis
*significantly reduces chance of transmission to 3%
Who should receive the HBV vaccine?
- ALL infants soon after birth (3 dose schedule).
Other than infants, who else should be vaccinated for HBV?
- children less than 18, frequent blood transfusions, dialysis patients, organ transplant recipients, prisoners, IVDA, household and sexual contacts of those with HBV, health care workers, multiple sexual partners
Is screening now recommended for pts born between 1945 and 1964?
YES bc CDC didn’t start screening blood prior to 1989.
*Test for HCV AB positive, confirmed by HCV RNA PCR
How do we now treat Hepatitis C infection?
Harvoni (ledipasvir/sofobuvir)= all oral, once a day treatment for genotype 1. These are direct acting antivirals that effect RNA polymerase, terminating viral replication.
- treat for 8-12 weeks. NO SIDE EFFECTS :)
- sustained viral response >90%
What drug came out this year for HCV treatment?
- Epclusa (sofosbuvir/velpatasir)= pan-genotypic for all genotypes with an SVR at 12 weeks of 98%!!!
- we don’t even have to genotype anymore with this.
What is the most common cause of liver transplants in the U.S.?
HCV cirrhosis
*can have recurrent infection if not eradicated prior to transplant.
Is there a vaccine for HCV?
NO, so prevention is dependent on avoiding high risk behaviors.
How do we treat Hepatitis D?
- no approved antiviral therapy for active infection.
- treatment is just supportive.
- treat the HBV with antivirals.
How do we prevent HDV infection?
- being immune to HBV
How do we treat HEV?
- no treatment; usually self-limited; care is supportive.
What are the 3 main non-viral causes of hepatitis?
- Non-alcoholic Steatohepatitis (NASH)
- Acute Alcoholic hepatitis
- Drug-Induced Liver Disease (DILI)
What is Non-alcoholic Steatohepatitis (NASH)?
- caused by fat deposition in the liver with INFLAMMATION; resembles alcoholic livers.
- This is distinguished from non-alcoholic fatty liver disease (NAFLD) which does NOT have inflammation.
- can progress to cirrhosis.
What are the risk factors for NASH?
- obesity, T2DM, high cholesterol, and metabolic syndrome
How is NASH diagnosed?
- elevated AST/ALT or CT (showing fat in liver).
How do we treat NASH?
- lifestyle modifications and long term vitamin E supplement.
What is acute alcoholic hepatitis?
inflammation of the liver from long term alcohol use.
- liver is the major site of ethanol metabolism and the resultant product is acetaldehyde= injury.
** How do we diagnose acute alcoholic hepatitis?
classic AST/ALT ratio elevation > 3:1
How do we treat acute alcoholic hepatitis?
- alcohol cessation, nutritional support and if DF >32 medicate (prednisolone or pentoxyfylline)
- liver transplant if bad enough (and must be sober for at least 6 months and been to AA or they won’t make the list).
What causes DILI?
- over the counter drugs, prescription meds, and herbal supplements bc the liver is the primary site for drug metabolism.
- most common cause of acute liver failure in the U.S.
What is the unique AST/ALT marker for DILI?
AST/ALT > 1000
Will you often see moderate liver enzyme elevations with the use of statins?
YES, just monitor and they should go back to normal.
How do you treat DILI?
- immediately stop the offending drug
- N-acetylcysteine as an antioxidant for acetaminophen toxicity.
What is the most common cause of liver transplant now?
HCV cirrhosis, but NASH will soon be the most common cause (unless lifestyles change).